Nursing Delegation in the School Setting
It is the position of the National Association of School Nurses (NASN) that, when necessary and permitted by law, the registered professional school nurse (hereinafter referred to as school nurse) can implement safe and effective delegation of nursing tasks to unlicensed assistive personnel, (UAP) at school. Delegation is an important practice component of the Care Coordination principle within NASN’s Framework for 21st Century School Nursing Practice (NASN, 2016). Safe nursing delegation requires that the school nurse is knowledgeable about the profession’s guidance on delegation, state nurse practice acts, (NPA), other applicable federal and state laws, and district policies (Resha, 2017; Mitts vs. Hillsboro Union High School, 1987). Proper delegation requires communication and collaboration between the school nurse, healthcare providers, school administrators, parents, teachers, and UAP. It is the position of NASN that a school nurse be present in school all day, every day to optimize student health, safety, and learning. However, current educational, health, safety, and economic conditions may necessitate the delegation of nursing tasks by the school nurse to unlicensed assistive personnel to protect every student’s right to quality school health services.
BACKGROUND AND RATIONALE
Delegation, as defined by the American Nurses Association, (ANA, 2012) is “the transfer of responsibility for the performance of an activity to another, with the former retaining accountability for the outcome” (p. 6). According to the National Council of State Boards of Nursing (NCSBN, 2016), “delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed” (p. 6). In the community setting of schools, delegation occurs when the school nurse assigns the performance of a specific nursing task to another person, often an UAP. Some states and school districts refer to UAP as paraprofessionals, health clerks, nursing assistants, health aides, or teacher’s aides (Bobo, 2014). The school nurse can only consider delegating nursing tasks that do not involve nursing judgment or any component of the nursing process, such as nursing assessment or developing individualized healthcare plans (ANA, 2012; Bobo, 2014; NCSBN, 2016).
School nurses face an ever-increasing workload, a concept that takes into account school nurse to student ratios, acuity, and factors that influence quality school nursing care in support of academic achievement including mental/emotional conditions and social determinants impacting health (Combe, et al., 2015). In addition, the legal responsibility of schools to ensure access to a free, appropriate public education (FAPE) for all children under Section 504 of the Rehabilitation Act of 1973 (Section 504), or the Individuals with Disabilities Education Act, (IDEA) puts school nurses at the forefront of ensuring that students with healthcare needs are identified and accommodated (Rehabilitation Act of 1973, Section 504; Individuals with Disabilities Education Act [IDEA], 2004).
The decision to delegate a nursing task in the school setting is the sole responsibility of the school nurse who must consider the needs of the individual student, as well as those of the school population, the stability and predictability of the student’s condition, school nurse workloads, documented training and competence of the delegatee, and the ability of the school nurse to supervise the delegatee, as well as the student’s health outcomes. (NCSBN, 2016; Shannon & Kubelka, 2013; Mitts vs. Hillsboro Union High School, 1987). Due to the complexity of delegation in the school setting and evidence that suggests delegation is a skill that nurses generally do not acquire in their educational preparation, school nurses should be provided educational opportunities to develop competence in the complex skills of delegation (Maningo & Panthofer, 2018).
Parents/guardians and school administrators need guidance in understanding the safety and legal requirements surrounding delegation as dictated by state NPA’s and federal regulations. Just as in other healthcare settings, safe and legal nursing delegation in the school setting must be supervised by a registered nurse who monitors delivery of care and periodically assesses the competence of the UAP (Johnson, 2017; Shannon & Kubelka, 2013). Unless otherwise guided by state law or district policy, the school nurse determines how closely to supervise and how often to reassess the UAP. If the school nurse determines that delegation is not safe and the UAP is not competent to complete the task for any reason, the school nurse must work with the school administration to identify a more qualified individual who is willing to accept the responsibilities of delegation. The school nurse may need to rescind delegation and make provisions for the needed health service until the newly assigned delegatee is competent to assume the responsibility to perform and document the delegated task (NCSBN, 2016).
State laws and regulations regarding delegation vary considerably and the school nurse must adhere not only to their own state's laws and regulations, but also those of other states for out-of-state school-sponsored events (Kappel, 2018). In addition, licensing laws must be considered to ensure that the school nurse can legally provide nursing services in the state where a school-sponsored event occurs (Kappel, 2018). New legislation often demands changes in school district policies and school districts must have a clear, current, and all‐inclusive school health services delegation policy that establishes safe practice and aligns with legal stipulations (Lineberry, Whitney & Noland 2018).
Current school nurse workloads (Willgerodt, Brock, & Maughan 2018), school district fiscal constraints, and the need to ensure FAPE make nursing delegation a potential strategy to meet the healthcare needs of students. Delegation is not appropriate for all students, all nursing tasks, or in all school nurse practice settings. Neither the NASN nor the NCSBN support delegating steps in the nursing process, including nursing assessment or the use of nursing judgment (NASN, 2016, NCBSN, 2016). Key factors guiding determination for delegation include state laws, rules, and regulations; the five rights of delegation; safety issues; individual student healthcare needs; health services capacities, and UAP competence.
NASN supports school nursing delegation of appropriate nursing tasks to UAPs as permitted by state laws and regulations to meet student health and safety needs. School nurses implement NASN’s Framework for 21st Century School Nursing Practice™ principle of care coordination through direct and delegated care of students with healthcare needs (NASN, 2016). The decision to delegate is a serious responsibility that the school nurse determines on a case‐by‐case basis, based on the needs and condition of the student, stability and acuity of the student’s condition, potential for harm, complexity of the task, and predictability of the outcome (ANA, 2012). Delegation is a complex skill requiring professional clinical judgment, critical thinking, and accountability for the outcome of the delegated task. When applied appropriately, delegation of nursing tasks to UAP can be safe, effective, and cost saving and can allow the school nurse to focus on professional practice that involves implementation of the nursing process (NCSBN, 2016).
American Nurses Association. (2012). Principles of delegation. Silver Spring, MD: Nursesbooks.org..
Bobo, N. (2014). Nursing delegation to unlicensed assistive personnel in the school setting: Principles for practice. Silver Spring, MD. National Association of School Nurses.
Combe, L.G., Bachman M.B., Bolatowski, R., Endsley, P.E., Hassey K., Maughan E., …Zeno, E., (2015) School nurse workload: Students are more than just numbers. NASN School Nurse, 30(5), 283–288. Retrieved from https://doi.org/10.1177/1942602X15596582
Individuals with Disability Education Improvement Act (2004), 20 U.S.C. 1400 et seq.
Johnson, K. (2017). Healthy and ready to learn: School nurses improve equity and access. The Online Journal of Issues in Nursing, 22(3), Manuscript 1. doi 10.3912/OJIN.Vol22No03Man01
Kappel, D.M. (2018). Unlocking Access to Nursing Care Across the Nation. NASN School Nurse, 33(3), 186–188. https://doi.org/10.1177/1942602X18765241
Lineberry, M.J., Whitney. E., & Noland, M. (2018). The role of school nurses, challenges, and reactions to delegation legislation: A qualitative approach. The Journal of School Nursing, 34(3), 222-231. doi:10.1177/1059840517741526
Maningo, M.J., & Panthofer, N. (2018) Appropriate delegation in ambulatory care nursing practice. Viewpoint, – American Academy of Ambulatory Care Nursing 40(1), 14-15.
Mitts, Carol v. Hillsboro Union High School district 3‐8 Jt et al., Washington County Circuit Court Case 87‐1142C (1987)
National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-33. https://doi.org/10.1177/1942602X15618644
National Council of State Boards of Nursing. (2016.) National guidelines for nursing delegation. Journal of Nursing Regulation, 7(1),5-14. Retrieved from https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf
Rehabilitation Act of 1973, 29 U.S.C. § 504
Resha, C. A. (2017). Process for Delegation in the School Setting. In C. Resha, V. Taliaferro (Eds.), Legal Resources for School Health Services. Nashville, TN. SchoolNurse.com
Shannon, R. A & Kubelka, S. (2013). Reducing the risks of delegation: Use of procedure skill checklist for unlicensed assistive personnel in schools, part 2. NASN School Nurse, September 2013, 222-226. doi:10.1177/1942602X134890030
Willgerodt, M.A., Brock, D. M., & Maughan, E.M. (2018). Public school nursing practice in the United States. The Journal of School Nursing, 34(3), 232-244. https://doi.org/10.1177/1059840517752456
Kathy L. Reiner, MPH, BSN, RN
Kim Bartholomew, BSN, BS, RN
Adopted: June 2019
This document replaces the position statement Delegation, Nursing Delegation to Unlicensed Assistive Personnel in the School Setting (adopted January 2014).
Suggested citation: National Association of School Nurses. (2019). Nursing Delegation in the School Setting (Position Statement). Silver Spring, MD: Author
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.